Ch. 1 Introduction to Assessment Flashcards
1
Q
What is the nursing process?
A
ADPIE! Assessment, diagnosis, plan, implement, evaluate
2
Q
The nursing process is linear T or F
A
False
3
Q
The first foundational step of the nursing process
A
Assessment!
4
Q
Critical Thinking
A
- The process of intentional and reflective judgment about nursing problems, where the focus is on clinical decision-making, to provide safe and effective care.
- thinks beyond “what if”
5
Q
Grounding/centering
A
focus and put energy back into the earth
6
Q
Creating intentions
A
Getting focused and ready to see the patient
7
Q
Preassessment phase includes
A
Heart centering, grounding/centering, and creating intention
8
Q
Be CLEAR acronym
A
- Center yourself, Listen Wholeheartedly, Empathize, Attention, Respect
- Takes all 5 senses( verbal and non-verbal)
9
Q
Holistic Care values
A
- Holistic philosophy, theories, and ethics
- Holistic nurse self-reflection, self-development and self-care
- Holistic Caring Process
- Holistic communication, therapeutic relationships, and healing environment and cultural care
- Holistic education and research
10
Q
Characteristics of collaborative professional communication
A
- assertive communication> be assertive and direct
- rounding
- hand off report
- SBAR documentation
11
Q
Each individual is unique T or F
A
True
12
Q
The art of listening includes
A
- being client focused
- Body posture
- use all senses & active listening
- be careful not to act too quickly
- requires energy and concentration
- Art of not knowing> what isn’t being said?
13
Q
Nonverbal Communication
A
No words just actions
- body posture
- facial expressions
- Gait/ movement
14
Q
Health Assessment
A
A systematic method of collecting and analyzing data for the purpose of planning client-centered care
15
Q
Assessment begins…
A
- at the first moment, the nurse meets the client
- first impressions
16
Q
Head-to-toe approach
A
starts at head and neck and progresses down the body, examining the feet last
17
Q
Why learn assessments?
A
- health assessment is a comprehensive assessment of the physical, mental spiritual, socioeconomic, and cultural status of an individual
- focuses on the functional abilities and physical responses to illness another structure
- assessment= painting a picture
18
Q
Components of a health assessment
A
- Health history
- Physical examination
- Documentation of data
19
Q
health history
A
data gathered about the clients health history, health conditions and diseases, family health history, lifestyle and risk appraisal, and life stress review
20
Q
Physical examination
A
a systematic approach, same order each time. Head-to-toe approach
21
Q
Documentation of data
A
Data collected from health assessments must be documented so that other healthcare providers can use the information
22
Q
Subjective data
A
symptoms, what one can’t see
- what the client says
- cannot feel or see as a provider
23
Q
Objective data
A
gathered data from the assessment
- what you can see ex. vital signs/ test data
24
Q
Comprehensive Physical Assessment
A
Includes health history, interview, and a complete head-to-toe examination of every body system
25
Focused Assessment
An assessment that pertains to a particular topic, body part, or functional ability rather than overall health status and it adds to the database created by the comprehensive assessment
26
System-Specific Assessment
A focused assessment limited to one body system
ex. resp. distress/ cardiac
27
Ongoing assessment
An assessment that is performed as needed, after the initial database is completed and ideally at every interaction with the client
28
Purpose of physical examination
- to obtain baseline data
- identify nursing diagnoses, collaborative problems and wellness diagnoses
- monitor the status of a previously identified problem
-to screen for health promotion
29
Preparation for physical exam
- prepare the environment: make the patient comfortable
- Prepare the client: introduce yourself, explain what you will be doing
30
Positions during the physical examine
- Sitting
- fowlers
- prone
-supine
- lateral(side laying)
- Sims(rectal exam)
- Lithotomy
31
Physical assessment techniques
- inspection
- palpation
- percussion
- Auscultation
32
Inspection
visual examinations, observing, inspecting the area, exposing only what you need to see, can use light instruments, DO NOT RUSH!!
33
Palpation
- Using touch to gather information
from different parts of hands to detect diff. characteristics
- warm hands and short fingernails
- look for edemas and uncomfortabilities
34
Percussion
Tap skin striking surface with fingertips to vibrate underlying tissues and organs
- flatness= muscle or bone
- dullness= liver or heart
- resonance= hollow/ normal lung
- Hyper-resonance= lung with emphysema
- Tympany= stomach was gas(air)
35
Auscultation
- Listening to sounds that the body generates
- direct( w/ stethoscope) or indirect(w/o stethoscope)
- pitch, intensity, duration, quality
36
Components of a general survey
1. Physical appearance and behavior
2. Body Type and posture
3. Gait and movement
4. Speech
5. Mental State and Affect
6. Dress, grooming, and hygiene
7. Vital signs
8. Height and weight
37
Why is a general survey important?
- initial impressions gained from preliminary observations direct the nurse to further examination
- requires attention to detail
38
Physical appearance and behavior
- a variety of general observations about the patient; age, gender, race, and culture
- identify signs of distress
- does the patient appear healthy?
- note the color of skin, any lesions/ sunburn
39
Body Type and Posture
- observe body posture, and body symmetry, and observe for evidence of spinal deformities
- observe general impression of nutrition(well-nourished, overweight)
- Observe evidence of distress( sitting in tripod position, S.O.B.
- Do they assume a comfortable position
- Any guarding or splinting an area that may indicate pain
40
Gait and Movement
-Observe gait; balanced and smooth symmetry
- do arms swing freely?
- does the patient require assistive devices?
- Note ease of movement or struggle
- is their any limitations?
41
Speech
-Is there difficulty with speech?
- Listen for tone, pace, quality, vocabulary and sentence structure
- do they respond appropriately
- any hesitations or language challenges
42
Mental status and affect
- determine the level of consciousness
- orientation to time, place, person and situation
- is the client disorientated?
- what is the client's mood?
43
Dress, grooming, and hygiene
- is the patient clean and well-groomed?
- Any odors?
- Are they dressed appropriately for the season?
44
Vital signs
- temperature
- blood pressure
- Pulse( heart rate)
- Respirations & pulse ox
- PAIN!
45
Normal values
newborn: 130 bpm, 30-60 resp., 80/40
Adult: 80bpm, 12-20 resp., <120/<80
Older Adult: 8, 12-20 resp., 120/80-160/95
46
Temperature
- Reflects the balance between the heat produced and the heat lost from the body and is measured in heat units called degrees
- F= 96.8-100.0 &C= 36-38
-Auxillary= 98.1
- oral= 99.1
- rectal= 100.1
47
Documenting temperature
- Always document the route
- single reading doesn't always mean a fever
Febrile: fever afebrile: no fever
48
Measurement of temperature
- oral - Surface - Core measurement
- auxiliary - tympanic
- DOCUMENT CORRECTLY
49
important principle ofTympanic Measurement
- senses body heat in the form of infrared energy given off by a heat source in the ear canal
- Tug ear up and back(adults)
- down(children)
50
Heart rate(pulse)
- wave a blood created by contraction of the left ventricle of the heart
- peripheral: away from the heart
- Apical: central pulse located at apex of the heart
60-100bpm average
51
Pulse Locations
Radial: radial side of forearm at the wrist
Brachial(elbow) and Carotid(neck) arteries
52
Pulse characteristics
-rhythm: dysrhythmia or arrhythmia
- volume/ quality: weak/ strong
: Ease of access
- Elasticity of the arterial wall
53
Respirations
- counting the number of ventilatory cycles, inhalation, and exhalation, each minute
-inspiration: active process
-expiration: passive process
54
Respiration Characteristics
- Apnea: cessation of breathing
- Tachypnea: quick shallow breathing
- Bradypnea: abnormally slow breathing
-rate
- rhythm
- volume/depth
- ease or effort
55
Blood pressure
the measure of the pressure exerted by the blood as it flows through the arteries
56
Systolic pressure
Pressure of the blood as a result of contraction of the ventricles, that is pressure at the height of the blood wave
- Top number
57
Diastolic pressure
Pressure when the ventricles are at rest, that is the lower pressure, present at all times within the arteries
-Bottom number
58
Pulse pressures
The difference between diastolic and systolic pressures
59
Factors that determine blood pressure
- Pumping ability of the heart
- Peripheral vascular resistance
- Blood viscosity
- blood volume
60
What can affect blood pressure
-age -race -nervous system
- medications -gender - caffeine
- crossed legs - body position
61
Orthostatic Blood Pressure
- Drop of 20mm/Hg or more systolic or a drop of 10 mm/Hg diastolic within 3 minutes after position change
- supine, sitting, standing
62
Maintaining healthy blood pressure
-eat a healthy diet with lots of fruits and veggies
- limit foods high in fat, salt, and sugar
- keep weight at a healthy level
- Don't smoke or use nicotine
- limit caffeine and alcohol
63
Pulse Oximetry
- a noninvasive method of monitoring oxygenation with a device that measures oxygen saturation. The oximeter emits light and a photosensor is placed on the finger and measures the light passing through and calculates the oxygen saturation
- >90% average
- >95% expected
64
Describe the best practice approaches to physical assessments in pediatric patients
infants: exam room warm, assess vitals while sleeping
Toddlers: most comfortable on the lap of a parent, more like a game, make them feel comfortable, and lots of praising
preschoolers: Has more fear, demonstrate on doll first, make them feel comfortable, will withdraw if they feel threatened
School-age: Develop rapport, ask about school/activities, thinking is concrete, avoid using medical jargon
Adolescents: Provide privacy, demonstrate respect, expose only areas that are needed, allow opportunities for questions with out caregiver
65
Safety procedures for health assessment
- hand hygiene
- follow standard precautions
-identify patient
- provide privacy
- position for safety and comfort
-utilize proper body mechanics
- document properly
66
Standard precautions
-USE WITH ALL PATIENTS
- mask on properly
- donning and doffing properly
67
Ways to prevent falls in healthcare facilities
- admission assesses all patients for fall risks
- utilize standard fall risk assessment tools
- Purposely hourly rounding
- Identify modifiable risk factors
- place call light within reach
- keep floors dry and room free of clutter
68
Ways to prevent falls at home
